Failure to Implement Abuse Policy After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its abuse prevention policy following a resident-to-resident altercation involving a resident with a history of sciatica, Parkinsonism, and bipolar disorder, who was moderately cognitively impaired. The incident occurred when the resident's roommate rummaged through their belongings, leading to a verbal exchange and the roommate throwing a pillow that struck the resident in the face and left side. Staff intervened and separated the residents, but the event was not recognized or treated as potential abuse at the time. Despite facility policies requiring prompt reporting of suspected abuse to local law enforcement and the implementation of interventions to prevent future incidents, these steps were not taken. The nursing note documented the altercation but incorrectly stated that no physical contact was made, and there was no indication that law enforcement was notified or that any follow-up interventions were put in place. The resident's care plan was not updated to reflect the incident or to include measures to prevent recurrence. Interviews with staff, including the social worker, DON, and administrator, revealed a lack of understanding and misinterpretation of what constitutes physical contact and abuse. The administrator acknowledged being aware of the incident but did not implement the abuse protocol, and the nurse on duty did not complete an incident report or notify authorities. The required investigational forms were not completed, and the facility's abuse policy and procedures were not followed, resulting in a failure to protect the resident and ensure appropriate reporting and intervention.